Nev. Admin. Code § 50.050
An affidavit referred to in subsection 4 of NRS 50.315 must be in substantially the following form:
State of Nevada }
}ss.
County of............................... }
I, ........................., being first duly sworn, depose and say:
That I am a ................ (occupation) employed by ................ (employer);
That a regular part of my duties is the withdrawing of blood samples from persons and I am authorized to do so by the ......................... (name of appropriate licensing or certifying agency);
That on ......................... (date) at ..... o'clock ...m., I withdrew a sample of blood in a medically accepted manner from a person known to me as ................ (name); and
That I kept the sample of blood in my sole custody or control and it remained in substantially the same condition as when I first obtained it until on ......................... (date) I delivered the sample to ................ (name of person) of the ................ (name of law enforcement agency).
I do hereby swear under penalty of perjury that the assertions of this affidavit are true.
...........................................................
Affiant's Signature
...........................................................
Affiant's Title
Subscribed and sworn to before me this
............. day of the month of ........... of the year ......
...................................................................................
Notary Public
Nev. Admin. Code § 50.050
NRS 50.315